Autopsy-Averse Hospitals Bury Their Mistakes

Thanks to the proliferation of crime procedural TV shows, most Americans understand the value of autopsies in identifying a catalog of biological factors that add up to being able to nab the perp. But in hospitals, medical mistakes are being buried without autopsies, and that’s a problem for safe, high quality medical care.

A recent report from ProPublica, Frontline and NPR makes clear that the autopsy, a valuable tool in posthumous diagnosis, is increasingly ignored.

In the middle of the last century, according to the report, autopsies were an integral part of American health care. They were performed on approximately half of all patients who died in hospitals to pinpoint the cause of death, to assess how effective were the treatments and to identify diagnostic errors. Today, only about 5 in 100 patients who die in hospitals are autopsied. Hospitals are not required to offer or perform autopsies.

The consequences are significant, writes ProPublica’s Marshall Allen.

“Diagnostic errors – which studies show are common – go undiscovered, allowing physicians to practice on other patients with a false sense of security. Opportunities are lost to learn about the effectiveness of medical treatments and the progression of diseases. Inaccurate information winds up on death certificates, undermining the reliability of crucial health statistics. For families that lose loved ones under mysterious circumstances, an autopsy can provide answers that would otherwise remain out of reach.”

Most deaths that occur in hospitals are deemed “natural.” If they are unexplained, unobserved or occur within 24 hours of admission, according to some state laws, they must be reported to local coroners or medical examiners. But those agencies rarely accept hospital cases unless foul play is suspected.

That means if someone dies for unclear reasons, it’s difficult to determine if someone or some procedure was at fault and should be held responsible. In addition to a natural aversion to finger-pointing and possible legal ramifications of accountability, the report says, hospitals are reluctant to conduct autopsies because it’s expensive.

“Hospitals have powerful financial incentives to avoid autopsies. An autopsy costs about $1,275. … But Medicare and private insurers don’t pay for them directly, typically limiting reimbursement to procedures used to diagnose and treat the living. Medicare bundles payments for autopsies into overall payments to hospitals for quality assurance, increasing the incentive to skip them.”

If the next of kin consents, a deceased patient’s doctor may order a clinical autopsy to explore the disease process in the body and determine the cause of death. But even at teaching hospitals, which are typically nonprofit and whose mission is education, autopsies are performed only in about 20 in 100 deaths. The rate at private and community hospitals, which constitute the lion’s share of U.S. facilities, can be close to zero. Some new hospitals are being built without a place to perform autopsies.

It’s not only hospitals that decline to conduct what can provide definitive answers to the questions surrounding death; many doctors, too, are autopsy-averse thanks to their growing reliance on and confidence in sophisticated diagnostic tools for living patients such as CT scans and MRIs.

But studies have demonstrated that doctors using these devices, as useful as they are, can make mistakes. The report refers to a review of academic studies by the federal Agency for Healthcare Research and Quality that found when patients were autopsied, major errors related to the principle diagnosis or underlying cause of death were found in 1 of 4 cases. In 1 of 10 cases, the error appeared severe enough to have led to the patient’s death. Critics of such studies claim that cases undergoing autopsy are typically the most complex, so it’s likelier that a doctor would make a mistake in these circumstances.

ProPublica interviewed pathologists who said they often find diagnostic errors. “We often identify things that the imaging study could not,” said one. Other supporters of the procedure said autopsies can help identify and resolve hospital-acquired infections, and improve the treatment of heart disease.

Advocates of more routine use of hospital autopsies have suggested ways in which they could be integrated into medical care and subsidized. Pay pathologists for doing them, pay bonuses to hospitals that reach certain autopsy rates, and penalize them if they don’t. Medicare should encourage more autopsies and use them as a performance standard. Insurance companies and the government could pay for them. But the former reject that notion, saying that autopsy is not reimbursed because it doesn’t prevent or treat a sickness or injury. And everyone is aware of the budgetary constraints on government.

Never mind that the cost of an autopsy is small relative to what’s spent on drugs, treatment and diagnostic imaging; that routine autopsies and the payoff could save lives and money.

Said one pathologist, “We are letting go of something which we could really use tomorrow to improve the health care of patients.”

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